HIV in Asia
July 2018—The Asia-Pacific region is home to nearly 60% of the world’s population and more HIV-positive people than any region outside sub-Saharan Africa. At the time that TREAT Asia was founded in 2001, there was a high prevalence of HIV in certain localities and among key population groups, including men who have sex with men, people who inject drugs, and sex workers. At the same time there was poor access to available treatment overall, and especially for members of these marginalized populations. While substantial progress has since been made to develop comprehensive local, national, and regional responses to combat HIV, troubling trends in recent years suggest that efforts need to be re-invigorated, stepped up, and better targeted to reach people most at risk.
UNAIDS reported that in 2017, there were an estimated 280,000 new HIV infections in the Asia-Pacific, bringing the total number living with HIV/AIDS in the region to 5.2 million.1 In 2017, approximately 170,000 people died from AIDS-related illnesses in the region,1 a 39% decline in deaths since 2010, but in some countries AIDS-related deaths have increased.2
Access to antiretroviral therapy (ART) in the region increased from 19% in 2010 to 53% in 2017, when approximately 2.7 million people had access to ART. However, this falls below the treatment access levels globally (59%). Large numbers of people living with HIV in the Asia-Pacific, including 29% of HIV-positive children under age 15, still do not have access to ART.1 Only 56% of HIV-positive pregnant women in Asia have access to the antiretroviral medicines needed to prevent mother-to-child transmission (PMTCT) of HIV. In fact, the Asia Pacific region lags well behind East and southern Africa in terms of ART and PMTCT coverage.1,3
People Most at Risk
HIV rates among key populations in Asia and the Pacific—people who inject drugs (PWID), men who have sex with men (MSM), transgender people, and sex workers—are far higher than among the general population. UNAIDS reports that in 2017, key populations and their sexual partners accounted for more than 84% of new HIV infections in the region.2 And while there is wide variation among countries and different key populations, testing rates generally remain low. In 2016 about half of PWID, MSM, transgender people, and sex workers had been tested for HIV during the previous 12 months and knew their HIV status.4 Other groups with increased vulnerability to HIV include migrant workers and women. Children and adolescents also lag behind adults in treatment rates, and often have higher death rates from HIV/AIDS-related causes.
The sharp rise in the number of new HIV infections among MSM in the region has continued, and sexual activity between men remains stigmatized and often hidden. HIV prevalence among MSM was 5% or higher in 10 of the 18 countries that reported these data to UNAIDS in 2017. The countries reporting the highest rates are Indonesia (25.8%), Malaysia (21.6%), and Australia (18.3%).2 Many urban areas have extremely high HIV prevalence among MSM, including Bangkok, Thailand (28.6%); Yangon, Myanmar (26.6%); and Yogyakarta, Indonesia (20.3%). Rates among younger men (aged 15 to 24 years) are especially high.5 Male-male sex remains illegal in a number of countries in the region and prevention programs for MSM remain limited. Studies in several countries have found high levels of risk behaviors among MSM, including having multiple sex partners and low rates of condom use. By 2020, almost 50% of all new infections in Asia could be in MSM, according to the UN Commission on AIDS in Asia. Unless the course of the HIV epidemic among MSM is changed, new infection rates among this population will surpass those among every other high-risk group in the region. Scale-up of HIV programs targeting MSM and reduction of the stigma and discrimination they frequently encounter are essential.
There is limited data on transgender people in Asia, but certain cities have reported high HIV prevalence in this risk population; for example, 30.8% in Jakarta, Indonesia, and 19.3% in Kuala Lumpur, Malaysia.5 Reported country rates of HIV in transgender people include 24.8% in Indonesia, 5.5% in Pakistan, 4.2% in Micronesia, 3.1% in India, 1.7% in the Philippines, and 1.4% in Bangladesh.3 Such data suggests substantial need for transgender-specific health services in order for them to access prevention and treatment interventions.
People Who Inject Drugs
One-third of the world’s population who inject drugs live in the Asia-Pacific5 and are at increased risk of HIV and hepatitis C infection. Many countries in the region still lack effective harm reduction programs, though some have taken steps in recent years to expand access to syringe exchange, overdose prevention, and opioid substitution therapy. In many countries drug laws often conflict with HIV prevention strategies, and the financial resources available for harm reduction programs are still far below what is needed. In 2017, UNAIDS reported that HIV prevalence among PWID was higher than 5% in 10 of the 14 countries in the region that provided that data, with much higher rates in some countries, including Myanmar (34.9%), the Philippines (29%), Indonesia (28.8%), Pakistan (21%), and Thailand (19%).2 In some cities this proportion is higher still: for example, 60.7% of PWID in Kota Pontianak, Indonesia, and 47.4% of PWID in Faisalabad, Pakistan, are living with HIV. In 2015 PWID accounted for 29-65% of new HIV infections among adults 15-49 in Afghanistan, Myanmar, Pakistan, and Vietnam.5
HIV prevalence among sex workers is over 5% in several countries in the region, with the highest reported rate in Papua New Guinea (17.8%).3 The rate is even higher in some urban areas. For example, Yangon, Myanmar, had a 24.6% prevalence of HIV among female sex workers in 2015. However, high condom use among female sex workers, with a medium regional rate of 81%, correlates with declining HIV rates in this population.5 There are significant efforts underway to study and implement PrEP programs for female sex workers in the region.
Economic upheaval over the past several decades has resulted in increased population mobility and environmental degradation, encouraging people to move to cities in search of better employment opportunities. Sexual transmission of HIV is exacerbated by this mobility, with migrant workers spending long periods of time away from home and potentially engaging in high-risk behaviors. Throughout the region, HIV continues to spread along trucking routes; among traveling sailors, fishermen, and migrant workers; and within the sex industry, which is itself fueled by economic disparity.
As elsewhere in the developing world, sex-based socioeconomic disparities play a significant role in the spread of HIV. Even when women know or suspect that their partners are HIV-positive or are having sex with multiple partners, they often have little power to insist on condom use. As a result of these and other factors, women accounted for 37% of adults with HIV in Asia in 2017—up from 20% in 1990.3
Children and Adolescents
AIDS-related deaths among 10-19 year olds almost quadrupled in South Asia between 2001 and 2015 (from 1,500 to 5,300), and they increased from 1,000 to 1,300 during the same period in East Asia and the Pacific.6 In 2017, there were 110,000 children age 14 and younger in Asia and the Pacific living with HIV.3
Programs to prevent mother-to-child-transmission have had varied success throughout the region, ranging from elimination of MTCT in Thailand to a 13% coverage rate for HIV-positive pregnant women in Indonesia.3 Approximately 56% of HIV-positive pregnant women in the Asia-Pacific are receiving ART to prevent infection in their babies, compared to 93% of HIV-positive pregnant women in East and Southern Africa.1 The overall regional rate of MTCT remains comparatively high, at 17%, and in 2017 only a quarter of HIV-exposed infants received early infant diagnosis.2 Many HIV-positive women remain reluctant to seek antiretroviral therapy or to bottle-feed their infants for fear of arousing suspicion regarding HIV status and confronting associated stigma and discrimination. Access to pediatric HIV treatment remains limited; in 2017 only 71% of HIV-positive children in the region were receiving antiretroviral treatment.1 Successful transition of infected adolescents from pediatric to adult HIV care remains a challenge, and adolescence is a particularly perilous time for youth who have been HIV positive since birth.
While there were 10,000 new infections in children 14 years of age and younger in 2017, 23% of new HIV infections in the Asia-Pacific region occurred in young people aged 15-24 years.1 There were approximately 50,000 new HIV infections among adolescents aged 15-19 in 2014, representing 15% of new infections in the region. Currently the Asia-Pacific has about 220,000 adolescents living with HIV. Adolescents from key populations, in particular young men who have sex with men, make up a large percentage of the increase in new infections in this age group. According to UNICEF and UNAIDS, it will not be possible to end the AIDS epidemic as a public health threat by 2030 without tackling the HIV epidemic among adolescents.6
National HIV Data
While the overall prevalence of HIV in most Asian countries remains low, there are expanding HIV epidemics among certain populations and in certain countries. The majority of new HIV infections in the region occur in 12 countries: In 2017 Cambodia, China, India, Indonesia, Malaysia, Myanmar, Nepal, Pakistan, Papua New Guinea, the Philippines, Thailand and Viet Nam together accounted for more than 97% of all new HIV infections. In some countries, including the Philippines and Pakistan, rates of new infections have increased since 2010.2
• In China in 2016, 660,000 people knew they were HIV positive, and 490,000 were on treatment.7 Among gay men the HIV prevalence is 7.8%; among people who inject drugs it is 5.9%, and among sex workers it is 0.2%.3
• In India, the estimated number of HIV/AIDS cases in 2017 was 2.1 million, down from 2.3 million in 2010. Although the overall HIV prevalence is 0.2%, among sex workers it is 1.6%, among PWID it is 6.3%, among MSM it is 2.7%, and among transgender people it is 3.1%. While the number of people on antiretroviral therapy has increased greatly, a high percentage of people with HIV do not get tested or access treatment until their disease has progressed to dangerous levels. About 79% of all people living with HIV in India know their status, and about 56% are on treatment.3
• Indonesia, the world’s fourth most populous country, had 49,000 new infections in 2017, compared to 61,000 in 2010. According to UNAIDS, in 2017 only 42% of people living with HIV were aware of their status, and only 14% of the 630,000 people living with HIV/AIDS were receiving antiretroviral therapy. Around a quarter of MSM, transgender people, and PWID were estimated to be HIV positive. There has been an increase in new infections among children, up to 3,100 in 2017 compared to 2,700 in 2010. This is despite an increase in the rate of pregnant women living with HIV accessing antiretroviral medicines, from 3% in 2010 to 13% in 2017. AIDS-related deaths increased from 23,000 in 2010 to 39,000 in 2017.2
• In Malaysia, 83% of people living with HIV have been diagnosed, but only 45% are on treatment. New infections increased from 7,200 in 2010 to 7,800 in 2017. There are fewer than 100 new infections per year among children and there is a greater than 95% treatment coverage rate among children. The percentage of pregnant women living with HIV accessing antiretroviral treatment is more than 95%. HIV prevalence among MSM is 21.6%, in PWID it is 13.5%, and among sex workers, it is 6.3%.3
• In Myanmar in 2017, 220,000 people were living with HIV. There was a 26% decrease in new infections, from 15,000 in 2010 down to 11,000 in 2017. About 6.4% of MSM are HIV positive; and of these, 52.4% know their status. About 5.4% of sex workers are HIV positive and 44.6% of them know their status. The prevalence of HIV among PWID is 34.9 %.2
• Pakistan saw a 43% overall increase in new infections from 2010 to 2017 (from 14,000 to 20,000), including a 29% increase among young people aged 15-24 years. During this time period, the number of people living with HIV more than doubled, from 66,000 in 2010 to 150,000 in 2017. AIDS-related deaths almost quintupled, increasing from 1,300 to 6,200. Only 8% of people living with HIV are on treatment. The HIV prevalence rate among PWID is 21% and the treatment coverage is 10.3%, but treatment coverage for other key populations is even lower—4.3% among sex workers, 3.2% among transgender people, and 0.1% among MSM.2,3
• In the Philippines in 2017, new HIV diagnoses were reported to be 173% higher than in 2010 (4,400 to 12,000), an alarming rate of increase. The vast majority of new infections were among MSM, particularly young men. About 4.9% of MSM are living with HIV; about 1.7% of transgender people are HIV-positive; about 0.6% of sex workers have HIV; and about 29% of PWID have HIV. While 36% of people living with HIV are on treatment; only 13% of children living with HIV are on treatment and only 11% of pregnant women with HIV are accessing antiretroviral medicine. Since 2010, new HIV infections among young people (aged 15-24 years) increased by 170%.2
• In Thailand, a country with a history of successful prevention efforts, overall HIV prevalence is 0.65%.3 There were 440,000 people living with HIV in 2017, compared with 510,000 in 2010.2 Between 2010 and 2016, there was a 50% decrease in annual new infections.7 Prevalence among people who inject drugs (PWID) remains high, at 19%, although it has declined somewhat in recent years. HIV prevalence among MSM in Thailand as a whole is at 9%,2 but in Bangkok MSM HIV prevalence is more than 28%.5 In Thailand, more than 95% of people living with HIV have been diagnosed, and 72% of HIV-positive people are on treatment.2
• In Vietnam, the estimated number of people living with HIV has increased from 230,000 in 2010 to 250,000 in 2017.2 However, there was a 34% decrease in new infections between 2010 and 2016, from 17,000 to 11,000.7 About 50% of people living with HIV are on treatment. Among key populations, 12.2% of MSM are living with HIV and 17.7% are on treatment; 14% of PWID are HIV positive and 53.4% are on treatment; and 3.7% of sex workers are living with HIV and 27.6%are on treatment.2
Mounting an Effective Response
Evidence from successful interventions in the region shows that prevention efforts targeting those at greatest risk are essential to stem the spread of HIV. Above all, to be effective in Asia, prevention messages will have to both acknowledge and challenge cultural stereotypes and expectations that often prevent frank discussion of issues surrounding sex and drug use. Communities face persistent challenges to overcoming the stigma that surrounds the disease and creates barriers to prevention and care, and those that are most affected must be central to developing an effective response. Laws that criminalize key populations must be changed, as well as discriminatory practices such as those that allow employers to screen their workers for HIV.
Mounting an effective response to the epidemic in Asia and the Pacific will require increasing the level of resources committed to HIV/AIDS programs, using those resources where they are most needed, and balancing the need for continued prevention efforts with the growing demand for HIV treatment. It also requires continued and increased political commitment, involvement of communities in the design and delivery of interventions, and the application of new technologies and interventions such as rapid testing and PrEP. Better collection and use of strategic information, including surveillance and program data, is necessary to ensure that effective interventions are focused where, when, and on whom they are needed. As HIV clinical and treatment outcomes of those infected with HIV improve, addressing the chronic care needs of people living with HIV and AIDS, including coinfections, comorbidities, and mental health concerns, becomes increasingly important.
1UNAIDS Fact Sheet—July 2018
2UNAIDS Data 2018, pages 124-171
4UNAIDS. Ending AIDS: Progress Towards the 90-90-90 Targets. Global AIDS Update, 2017, pages 122-127.
5UNAIDS Prevention Gap Report 2016, pages 126-140
6UNICEF, UNAIDS and partners: Adolescents: Under the Radar in the Asia-Pacific AIDS Response
7UNAIDS Data 2017, pages 76-111